It looked like it was going to be a bad call on pediatrics. Signout was full of new, borderline admissions -- asthma exacerbations that were already improved, a rule-out sepsis or two with the mildest of fevers. Plus, we got word that two more RSV's were heading up to the floor.

On rounds we learned that the patients slated for discharge didn't want to leave -- or at least, the parents didn't want them to. I caught a mom feeding her (supposedly NPO) baby, then complain of his vomiting, five minutes later.

I was quickly becoming as cranky as some of the infants.

As the day wore on, though, the work got done. The new admissions were straightforward, the language barriers were easily surmounted. I still felt like a cog in a vast, inefficient machine, but at least we were moving forward.

When an opportunity for sleep presented itself in the evening, I took it. As I drifted off, I recalled an episode from morning conference, earlier in the week:

One of the residents has presented a potentially interesting case of progressive lower extremity weakness in a twelve year old girl -- the differential included Guillian-Barre syndrome and cord compression. Workup had been negative, and when it came time to do electromyography, the kid fought off the needles -- vigorously. She had been faking it, for days.

We then discussed conversion disorder vs. factitious disorder, a psychiatry consult was decided upon, and it was my turn to present a case. I had a two month old with cough that just wouldn't quit. At the top of my differential, I jokingly put "malingering." Everyone laughed, but I remembered thinking that such a remark a few wouldn't have occurred to me, a few months ago. Floor medicine was jading me, far more than any experiences in the emergency room.

Sleep that night was fair enough -- just one call to the floor (the NPO baby had somehow managed to spit up milk again). At around midnight, my resident woke me.

"A new admission?" I asked.

"Actually," she replied, "kind of the opposite." The pediatric emergency department was swamped, and the attending was requesting another set of hands. My resident, like any good resident, was protective of her call intern, but knew I was in EM and might agree to it.

"Sure," I said.

And so I went down to the peds ED, which was indeed busy. I only saw a few patients; just enough for the attending to get a handle on the situation. But in that short time, I got away from those perfunctory floor exams and took real histories, real physicals, and made real decisions on the info I'd collected. I reassured some nervous parents, made a few kids smile, and generally felt like I was making a difference.

It's been months since I've been assigned to the emergency department, and it will be months until I'm formally back. But this little midnight ED stint was more refreshing to me than any sleep -- making my last call for 2005 my best.